Portal Hypertension: Imaging, Diagnosis, and Endovascular Management

Description

Previously published by the Society for Interventional Radiology (SIR), this fully revised and updated third edition of Portal Hypertension: Imaging, Diagnosis, and Endovascular Management is the first volume in collaboration between Thieme and the SIR. Edited by Wael Saad and written by internationally recognized experts, this authoritative volume is a comprehensive guide to the diagnosis and interventional management of portal hypertension. A serious condition, portal hypertension presents considerable clinical challenges due to the delicate nature of the impacted organs, veins, and vessels. From pathophysiology to the latest state-of-the-art approaches, five major sections encompass diagnostic, medical, endoscopic, non-vascular, surgical, percutaneous, endovascular, and balloon-occluded methodologies, including indications, complications, and clinical trial results. Throughout this book's 31 chapters, a Who's Who of world-renowned interventional radiologists share clinical pearls and step-by-step procedural guidance. Several advanced techniques have been developed since the second edition was published, including Transjugular Intrahepatic Portosystemic Shunt (TIPS), Balloon-Occluded Retrograde Transvenous Obliteration (BRTO), Balloon-Occluded Retrograde Transvenous Obliteration (BRTO), and variations on TIPS, and these are featured herein. Key Highlights Hepatic and portal venous anatomy relative to procedural approaches Nearly 250 figures elucidate anatomical structures and technical methodologies TIPS: patient selection, effects on kidney and liver function, hemodynamic changes, intravascular ultrasound guidance, Doppler surveillance, and utilization for Budd-Chiari Syndrome and liver transplantation TIPS clinical study outcomes for variceal bleeding, ascites, and hydrothorax BRTO and BATO techniques, clinical study outcomes, and utilization for gastric varices Management of mesenteric and portal vein stenosis, thrombosis, and hypersplenism This remarkable book is a must-have tool for interventional radiologists and for all those who care for patients with portal hypertension, from residents to practicing clinicians. Portal Hypertension Contents Preface Section I P a t hogenesis and Diagnosis Chapter 1: P a t hophysiology and Classification of Liver Cirrhosis and Po L i v er Anatomy and Function L i v er Cirrhosis: Definition, Classification, and Epidemiology Definition of Classification of Cirrhosis Epidemiology of Cirrhosis Hepatitis B Virus Alcoholic Liver Disease Hepatitis C Virus Nonalcoholic Fatty Liver Disease Definition and Classification of P ortal Hypertension Definition of Portal Hypertension A utoimmune Hepatitis Classification of Portal Hypertension Budd-Chiari Syndrome C onclusion Clinical Pearls Chapter 2: Clinical Presentation of Portal Hypertension V arices C omplications from Cirrhosis and P ortal Hypertension Ascites Spontaneous Bacterial Peritonitis Hepatorenal Syndrome Serum-Ascites Albumin Gradient P ortopulmonary Hypertension and Hepatopulmonary Syndrome Hepatic Hydrothorax Hepatic Encephalopathy S ymptoms and Physical Examination Laboratory Evaluation R adiologic Evaluation C onclusion Clinical Pearls Severity of Liver Disease Scoring Systems R e f erences Chapter 3: Noninvasive Cross-Sectional and Vascular Imaging of Portal Hyp V enous Pathways in Portal H ypertension 1. E sophageal and paraesophageal varices 2. G astric varices 3. P araumbilical varices and abdominal wall varices 4. P erisplenic varices 5. R e troperitoneal varices 6 . R ectal varices 7 . S hunts Noninvasive Imaging Diagnosis Ultrasonography C omputed Tomography C ontrast-Enhanced Computed T omography V ariceal Hemorrhage Intrahepatic Shunts Arterioportal Shunts P ortosystemic Shunts Thrombosis and Calcifications Cavernous Transformation V olumetrics Aneurysms and Varices Bidimensional and Three-Dimensional R endering Magnetic Resonance Imaging Magnetic Resonance Venography Novel Magnetic Resonance Imaging T echniques P hase Contrast T1 Mapping Magnetic Resonance Elastography Summary Clinical Pearls Chapter 4: Indirect Portal Pressure Measurement and Carbon Dioxide Wedged C omparison of End-Hole and Balloon Catheters for HVPG Measurement Indirect Portal Pressure Measurement T echnique The Use and Prognostic Implications of Indirect Portal Pressure Measurement W edged CO 2 Portography Characteristics of Carbon Dioxide Preparation and Use of CO 2 C omparison of Iodinated C ontrast with CO 2 C omplications of Wedged CO 2 P ortography Chapter 5: Hemodynamic Evaluation of the Liver and T r ansjugular Liver Bio Preprocedure Preparation T echnique Hemodynamic Evaluation of the Liver Material Required for the Procedure C omplications Interpretation of the Hepatic V enous Pressure Gradient T r ansjugular Liver Biopsy T r ansjugular Liver Biopsy Technique Materials C omplications Specimens 6 Medical Management of Portal H ypertension C omplications Section II Medical, Endoscopic, Percutaneous,and Surgical Management Chapter 6: Medical Management of Portal H ypertension C omplications Anatomy and Physiology G a s t rointestinal Varices Clinical Pathophysiology Esophageal Varices Primary Prophylaxis T reatment of Variceal Hemorrhage G a s t ric Varices Hepatic Encephalopathy Secondary Prophylaxis P ost-TIPS Hepatic Encephalopathy Ascites Large-Volume Paracentesis T r ansjugular Intrahepatic P ortosystemic Shunt Hepatic Hydrothorax L i v er Transplantation Hepatorenal Syndrome Spontaneous Bacterial Peritonitis P ortopulmonary Hypertension C onclusion Clinical Pearls R e f erences Chapter 7: Endoscopic Classification and Management of Varices Esophageal Varices Screening Management: Primary Prophylaxis Classification Endoscopic Variceal Ligation Endoscopic Sclerotherapy T echnique S hunt Surgery Operations and TIPS Endoscopic Sclerotherapy Management of Esophageal V arices Hemorrhage Esophageal Stents Endoscopic Variceal Ligation T r ansjugular Intrahepatic P ortosystemic Shunt Cyanoacrylate Injection Surgical Decompression G a s t ric Varices T echnique Balloon-Occluded Retrograde T r ansvenous Obliteration and T r ansjugular In Management E ctopic Varices R e f erences Chapter 8: P aracentesis and the LeVeen and Denver Shunts Large-Volume Paracentesis Procedure P eritoneovenous Shunts Procedure S hunt Evaluation and Repair Clinical Pearls: Ascites Clinical Pearls: Large-Volume P aracentesis Clinical Pearls: Disseminated Intravascular Coagulopathy (Consumptive Coagul Clinical Pearls: Paracentesis- Induced Circulatory Dysfunction Clinical Pearls: Peritoneovenous S hunt Clinical Pearls: Spontaneous Bacterial Peritonitis Chapter 9: Surgical Management of Portal Hypertension General Considerations A c ute Management of Recalcitrant V ariceal Bleeding Devascularization Procedures Emergent Management of Active V ariceal Bleeding P ortal Decompressive Shunt Surgery T o tal Portosystemic Shunts P ortacaval Shunt Mesocaval Shunt C entral Splenorenal Shunt Selective Shunts P artial Portosystemic Shunts Special Circumstances Budd-Chiari Syndrome Extrahepatic Thrombosis of the Portal Vein Surgical Management of Intractable Ascites R e f erences Isolated Splenic Vein Thrombosis Chapter 10: Percutaneous Management of Surgically P laced Portosystemic Shu Indirect Portography S hunt Catheterization Through t he Inferior Vena Cava Diagnosis of Shunt Dysfunction Chapter 10: Percutaneous Management of Surgically Placed Portosystemic Shunts Thrombolysis of Clotted Shunts T reatment of Dysfunctional Shunts Balloon Dilatation of the Malfunctioning F ollow-Up and Treatment of Shunt Dysfunction S t enting of Strictured Shunts R e sults and Discussion Emergency Variceal Embolization and Sclerosis 11. P a t ient Selection and t he Effect of T r ansjugular Int Section III Endovascular Management: S hunts and Splenic Embolization Chapter 11: P a t ient Selection and the Effect of Transjugular Intrahepat P a t ients with Portal Hypertension w ith Esophageal Varices Who Have Nev The Role of Transjugular Intrahepatic Portosystemic Shunt in P a t ients P a t ients with Acute Variceal Hemorrhage P a t ients with Portal Hypertension Who H a v e Not Developed Esophageal Var P a t ients Who Have Survived a Bleeding Episode and Require Treatment to P The Role of Transjugular Intrahepatic Portosystemic S hunt in P a t ien C onclusion Effect of Transjugular Intrahepatic P ortosystemic Shunt on Liver and Kidney Clinical Pearls Chapter 12: Hepatic and Portal Venous Anatomy Relative to t he Transjugular L i v er Morphology and Anatomy Hepatic Venous Anatomy Right Hepatic Vein Middle Hepatic Vein L e ft Hepatic Vein V ariant Anatomy P ortal Venous Anatomy Right Portal Vein L e ft Portal Vein Anatomic Variants P a t hophysiologic Variants Spatial Relationship of Hepatic and Portal Veins P a t hophysiologic Variants Imaging Options P ortal Hypertension and P ortosystemic Collaterals Clinical Pearls R e f erences Chapter 13: T echnique for the Transjugular Intrahepatic P ortosystemic Shu Historical Note Procedure Planning Present Status The Procedure Hepatic Vein Catheterization P ortal Vein Access Set W edged Hepatic Venogram P ortal Vein Access Pressure Measurements and Portal V enography Endograft Deployment V ariceal Embolization P ostprocedural Management P eriprocedural Complications and Their Prevention R e f erences Chapter 14: The Difficult Transjugular Portosystemic Shunt Procedure: Unconven Indications and Contraindications L i v er Parenchymal Problems Procedures A c c e s s Problems Hepatic Vein Problems P ortal Vein Problems P oral Vein Occlusion Outcomes Clinical Pearls R e f erences Chapter 15: The Intravascular Ultrasound Guided Direct Intrahepatic Portaca E quipment F emoral Access Jugular Access E quipment Modifications R ösch-Uchida Liver Access Set Needle and Catheter (Puncture Needle Set) Intravascular Ultrasonography The Procedure S t ep 1: Femoral Venous Access and Intravascular Ultrasound Placement S t ep 3: The Transcaval Puncture S t ep 2: Placement of the Modified RUPS S t ep 4: Upsizing the Guidewire S t ep 5: Portography, Manometry, and T r act Measurement S t ep 6: Intravascular Ultrasound Guided Placement of the VIATORR S t ent C ontrol of the Extrahepatic Puncture C onclusion Direct Intrahepatic Portacaval S hunt Patency A c knowledgments Clinical Pearls Chapter 16: Hemodynamic Changes Following the T r ansjugular Intrahepatic Por Intrahepatic Hemodynamic Changes After TIPS Hemodynamics of Cirrhosis and P ortal Hypertension in Brief S y s t emic Hemodynamic Changes and Clinical Implications for Hepatorenal S R e f erences C onclusion Clinical Pearls Chapter 17: Budd-Chiari Syndrome: Transjugular Intrahepatic P ortosystemic Sh Hepatic Venous Recanalization S t r a t egies to Recanalize Hepatic V enous T reatment of Budd-Chiari S yndrome T echnique of Inferior Vena Cava R ecanalization T echnique of Hepatic Vein R ecanalization 3. C ombined transhepatic transvenous approach ( ▶ F i g. 17.5): R e sults and Complications of Hepatic V enous Outflow R ecanalization T echnique of Combined Inferior Vena Cava and Hepatic Vein Recanalization T echnique of Transjugular Intrahepatic P ortosystemic Shunt in Budd-Chiari T r ansjugular Intrahepatic P ortosystemic Shunt R e f erences R e sults and Complications of Transjugular Intrahepatic P ortosystemic S C onclusion Chapter 18: Transjugular Intrahepatic Portosystemic Shunt R eduction for Post Indications for Transjugular Intrahepatic Portosystemic S hunt R eduction R e sults R eduction s Predecessor: T r ansjugular Intrahepatic P ortosystemic Shunt O Early Transjugular Intrahepatic P ortosystemic Shunt Reduction T echniques: Balloon-Expanded Stent Graft Sculpting T echniques R e sults Modern Techniques: Reducing S t ent Grafts R e sults Purse-String Suture Mediated R eduction Technique C oaxial Constraining Stent-Over-Stent-Graft T echnique R e sults P arallel Constraining Stent and Stent Graft Technique R e sults Lasso Technique R e sults Other Transjugular Intrahepatic P ortosystemic Shunt Reduction Studies, Prod C onclusion Clinical Pearls R e f erences Chapter 19: Patency Outcomes of Transjugular Intrahepatic P ortosystemic Shun Histopathology of Shunt Stenosis The Development of TIPS Endografts Animal Studies Medical Approaches to Inhibit S hunt Stenosis Early Human Experience Outcomes of Bare Versus Commercially A v ailable Covered Stents P a t ency Outcomes of Endograft Use in Budd-Chiari Patients P ediatric TIPS and Endografts R a t ionale for Use of Uncovered S t ents in Some TIPS R e f erences C onclusion Chapter 20: Doppler Surveillance of Transjugular Intrahepatic P ortosystemic Sonographic Terminology Normal Gray-Scale and Doppler Findings Normal Transjugular Intrahepatic P ortosystemic Shunt Examination Ultrasonog A bnormal Transjugular Intrahepatic P ortosystemic Shunt Examination S t ent S hunt Stenosis Main Portal Vein Velocity Intrastent Flow Velocity Intrahepatic Portal Vein Flow Direction Hepatic Artery Velocity Hepatic Venous Flow Other Complications P itfalls and Artifacts T r ansjugular Intrahepatic Portosystemic S hunt Stent P ortal Vein Clinical Pearls R e f erences Chapter 21: Transjugular Intrahepatic Shunts for Variceal Bleeding: Results o Prevention of Variceal Rebleeding: Early Clinical Studies The Era of Stent Grafts Current Practice Guidelines Primary Prevention of Variceal Bleeding A c ute Bleeding G a s t ric Varices Early TIPS E ctopic Varices V ariceal Embolization R e f erences C onclusion Clinical Pearls Chapter 22: Transjugular Intrahepatic Portosystemic Shunts f or Ascites and H T reatment Options First-Line Therapy P a t hophysiology and Pressures Second-Line Therapy Indications and Contraindications Prospective Cohort Trials: TIPS for Ascites R e sults of Clinical Studies: TIPS for R e fractory Ascites Outcome Variables • Q uality of life and cost R andomized Trials: TIPS versus Large-Volume Paracentesis Outcomes R eduction in Ascites C omplications Encephalopathy Survival Overall Efficacy for Management of Ascites Current Ongoing Studies Meta-Analyses of Randomized C ontrolled T r i als T IPS for Hepatohydrothorax C onclusion Clinical Pearls R e f erences Chapter 23: The Transjugular Intrahepatic Portosystemic S hunt as a Prelude t T IPS as a Preoperative Prelude to L i v er Transplantation T IPS in Liver Transplant Recipients T echnical Aspects P i ggyback Anastomosis Clinical Outcome MELD Score and Survival for TIPS After T r ansplant Split Grafts, Especially Left Lobe Grafts C omparative Analysis of Technical Outcomes Between TIPS in Hepatic Grafts a P osttransplant TIPS for Ascites Indications Unique to Posttransplant P a t ients Clinical Pearls C onsiderations in Posttransplant P a t ients R e f erences C onclusion Chapter 24: Management of Mesenteric and Portal Vein Thrombosis in Nontranspl Mesenteric and Portal Vein Thrombosis Epidemiology and Classification Clinical Presentation, Diagnosis, and Sequelae T r ansjugular Intrahepatic P ortosystemic S hunt Creation C onventional Medical and Surgical Therapies Interventional Radiologic Management Approaches and R a t ionale Direct Portal and Mesenteric Vein Thrombolysis and Thrombectomy P ortal Vein Recanalization for Chronic Occlusion P a t ient Selection Procedure Indications Procedure Contraindications Indirect Mesenteric and Portal V ein Thrombolysis via the Superior Mesenteri Procedure Technique and P eriprocedure Patient Care General Considerations Direct Mesenteric and Portal Vein Thrombolysis and Thrombectomy T r ansjugular Intrahepatic P ortosystemic S hunt Creation Indirect Mesenteric and Portal V ein Thrombolysis via the Superior Mesenteri Procedure Outcomes T r ansjugular Intrahepatic Portosystemic S hunt Flow-Enhanced Clot Dissoluti P ortal Vein Recanalization for Chronic Occlusion Direct Mesenteric and Portal Vein Thrombolysis and Thrombectomy T r ansjugular Intrahepatic P ortosystemic S hunt Thrombolysis and Throm Indirect Portal and Mesenteric V ein Thrombolysis via the Superior Mesenteri P ortal Vein Recanalization for Chronic Occlusion with Combined Therapeuti C onclusion R e f erences Procedure-Related Complications Chapter 25: Percutaneous Mesocaval Shunts T echnique C ombined Transabdominal and T r ansvenous Approach Indications and Contraindications Exclusively Transvenous Approach Outcomes T echnical and Hemodynamic Results C onclusion Clinical Outcomes R e f erences Chapter 26: Splenic Artery Embolization for Management of H ypersplenism an R e sults and Outcomes Hemodynamic Results Clinical Outcome T r ansplant Population C ombination Therapy Procedural Aspects C omplications C onclusion Clinical Pearls T echnical Pearls Outcomes Pearls R e f erences Chapter 27: Pediatric Portal Interventions T echnique T r ansjugular Intrahepatic P ortosystemic Shunts (TIPS) V ariceal Sclerotherapy P ortal Vein Recanalization Splenic Embolization C ongenital Portosystemic Shunts R e f erences P e arls/Take-Home Points Section IV P ercutaneous and Endovascular Management: Transvenous Obliteration Chapter 28: V a scular Anatomy and Classification Schema of Gastric Varice Afferent (Portal Venous Inflow) F eeder(s) Descriptive Anatomy Efferent Systemic Venous Drainage The Gastrorenal Shunt C entral Variceal Part of the Gastric V ariceal System P ericardiophrenic Vein R e t roperitoneal Veins V ariations in Systemic Venous Drainage Classifications S aad Gastroduodenal and Mesenteric V ariceal Classification and Classificati Hirota Balloon-Occluded Retrograde V enography Classifications and Kiyosue C S aad Classification for Afferent Inflow and Efferent Outflow of G a s t roesop Kiyosue Classification for Afferent Inflow and Classification-Based Management F ukuda-Hirota Hemodynamic Classification for Gastric Varices Matsumoto Hemodynamic Classification of Gastric Varices f or Predicting the C onclusion Chapter 29: The Conventional Balloon-Occluded Retrograde T r ansvenous Oblite Indications and Contraindications T echnique of the Balloon- Occluded Retrograde Transvenous Obliteration Proc A c c e s s and Approach Catheter Selection of the G a s t rorenal S hunt G a s t r ic Variceal System Occlusion T r apping Balloon Positioning, Manipulation, and Occlusion V enous Collateral Embolization or Obliteration Balloon-Occluded Retrograde Venography C one-Beam Computed Tomography Imaging (if Used) Indwelling Balloon Inflation (Sclerosant Dwell Time) Balloon Deflation and Removal Chapter 30: Balloon-Occluded Antegrade Transvenous Obliteration and Variati T echnique Balloon-Occluded Antegrade T r ansvenous Obliteration P ortal Venous Routes S y s t emic Venous Routes R outes for Gastric Varices R outes for Duodenal Varices C onclusion Clinical Pearls R e f erences Chapter 31: Clinical Outcomes of Balloon-Occluded R e t rograde Transvenous O Candidates for the BRTO Procedure T echnical Success P ostprocedure Imaging Evaluation Clinical Outcomes R e f erences Clinical Pearls Chapter 32: Management of Duodenal Varices Anatomy and Pathophysiology and Hemodynamic Classification Management of Duodenal Varices Endoscopy and Imaging T IPS Decompression with or without R ecanalization C onclusion T r ansvenous Obliteration R e f erences Chapter 33: Management of Stomal Varices Classification Anatomy Endoscopy and Imaging Management T r ansvenous Obliteration T IPS Decompression R e f erences C onclusion Clinical Pearls Index